Diabetic Ketoacidosis (DKA)
(Last Updated - 11/21/2006)

-characterized by a high Anion Gap initially which normalizes w/ treatment

-Treatment:
   1) IVF's:
      -Usual deficit --> 6-8 L
      -NS 1L over 1st hour then 300-500 mL/hr over next 12 hrs
      -Then 200-300 mL/hr w/ 1/2-NS until glucose < 300 then switch to D5W to prevent hypoglycemia

   2) Insulin:
      -Initial loading dose of 0.15-0.2 units/kg of Regular then 0.1 units/kg/hr
      -Monitor serum glucose QHr for 1st 2 hrs then Q2-4 hrs
      -Goal: Drop serum glucose by 80 mg/dl/hr --> if not reaching then double Insulin gtt
      -When serum glucose is ~250 --> decrease Insulin gtt to 1-2 units/hr and continue until adequate fluid replacement achieved (HCo3- normal & ketones normal)
      -30-60 mins prior to stopping Insulin gtt give a SQ dose of Regular (due to IV Regular's short 1/2-life)
      -When able to eat --> NPH 10-15 units QAM & RISS

   3) Electrolytes:
      A) Potassium (K+):
         -Total K+ loss is 300-500 mEq

         -As long as there is no EKG evidence of hyperkalemia:
            1) Peaked T-waves
            2) Decreased or absent P-waves
            3) Shortened QT intervals
            4) Widened QRS complexes

      B) Phosphate:
         -If serum Phos < 1.5 mEq/L then give 2.5 mg/kg IV of elemental Phos over 6 hrs
         -Must check Ca2+ prior to Phos admin --> IV Phos can cause hypocalcemia

      C) Magnesium (Mg2+):
         -Only given for significant hypomagnesemia or refractory hypokalemia

   4) Bicarbonate (HCo3-):
      -ONLY for pH < 7.0 b/c may worsen hypokalemia, intracellular acidosis & cerebral edema
      -Give 44-88 mEq of Na-HCo3 in 1 L of 1/2-NS Q2-4 hrs until the pH > 7.0



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